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The current budgetary allocation of ₹20 billion under the Pradhan Mantri Jan Arogya Yojana (PMJAY) is grossly inadequate. Our paper estimates that in the current fiscal year, the scheme will require an allocation of at least ₹420.73 billion to be able to give any meaningful coverage to 0.1 billion targetted families. This paper argues that such an expensive tertiary sector- led medical care coverage model is not the correct approach to ensure Universal Health Care (UHC) in India. A majority of illnesses are treatable at the primary level and an unbalanced promotion of the tertiary sector while neglecting primary healthcare will cause a delay in treatments, resulting in more complex and expensive medical interventions. What India urgently needs is to develop a comprehensive primary healthcare system.

The Profession held a joint seminar on ‘Human Genetics: Uncertainties and the Financial Implications Ahead’ with the Royal Society of London in September 1996. Papers submitted to that seminar included four from the profession and several from the medical, legal, social and scientific communities.This Sessional Meeting is designed to provide a forum for discussion amongst a wider actuarial audience. The topic is important to the profession, not only in relation to life insurance, but perhaps even more in relation to health insurance. The four papers by the actuarial authors are reproduced, together with a short third party summary of the whole seminar and a more detailed summary by C.D. Daykin of the actuarial, legal and social points raised in the discussions.The meeting takes the form of a panel discussion. Each of the panellists is to be invited to make introductory comments on their papers to update them where appropriate in the light of developments since September 1996 (for example the ABI statement) and will also suggest specific topics for discussion at the meeting. There is then an opportunity for members and guests to raise and debate all relevant issues.

The COVID-19 pandemic has led to disruptions in healthcare utilization and spending. While some changes might persist (e.g. substitution of specialist visits by online consultations), others will be transitory (e.g. fewer surgical procedures due to cancellation of treatments). This paper discusses the implications of transitory changes in healthcare utilization and spending for risk adjustment of health plan payment. In practice, risk adjustment methodologies typically consist of two steps: (1) calibration of payment weights for a given set of risk adjusters and (2) calculation of payments to insurers by combining the calibrated weights with enrollee characteristics. In this paper, we first introduce a simple conceptual framework for analyzing the (potential) distortions from the pandemic for both steps and then provide a hypothetical illustration of how these distortions can lead to under- or overpayment of insurers. The size of these under-/overpayments depends on (1) the impact of the pandemic on patterns in utilization and spending, (2) the distribution of risk types across insurers, (3) the extent to which insurers are disproportionately affected by the pandemic, and (4) features of the risk adjustment system.

Taxi and for-hire vehicle (FHV) drivers are a predominantly immigrant population facing a range of occupational stressors, including lack of workplace benefits and increasing financial strain from tumultuous industry changes and now COVID-19’s devastating impact. Bilingual research staff surveyed 422 New York City taxi/FHV drivers using a stratified sampling approach in driver-frequented locations to examine drivers’ health and financial planning behaviors for the first time. Drivers lacked health insurance at double the NYC rate (20% vs. 10%). Life insurance and retirement savings rates were lower than U.S. averages (20% vs. 60%, 25% vs. 58%, respectively). Vehicle ownership was a significant predictor of health insurance, life insurance, and retirement savings. Compared to South Asian drivers, Sub-Saharan African drivers were significantly less likely to have health insurance and North African, and Middle Eastern drivers were significantly less likely to have retirement savings. Although most drivers indicated the importance of insurance and benefits

This paper contributes to the discussion around ex-post (increased utilisation of health care) and ex-ante (changes in health behaviours) moral hazard in supplemental private health insurance. Applying a range of methodologies to data from the Russian Longitudinal Monitoring Survey—Higher School of Economics we exploit a selection mechanism in the data to compare the impact of workplace provided and individually purchased supplemental health insurance on the utilisation of health care, on a range of health behaviours and on self-assessed health. We find compelling policy-relevant evidence of ex-post moral hazard that confirms a theoretical prediction and empirical regularity found in other settings. In contrast to other empirical findings though, our data reveals evidence of ex-ante moral hazard demonstrated by clear behavioural differences between those with self-funded supplemental health insurance and those for whom the workplace finances the additional insurance. We find no evidence that either form of insurance is related to improved self-assessed health.

Background A common narrative is that high prices are necessary for "orphan drugs" because of the fewer patients. In the context of state health insurance systems, the high prices create significant challenges because of limited budgets. Results This study carefully examines both costs and revenues of two drugs for cystic fibrosis (ivacaftor and lumacaftor), showing that, for this important example, prices are not high because of fewer patients. The study then explores the justifications usually given for high orphan drug prices, including the need to support research and development for new drugs. Each of these standard justifications is shown to be inadequate; instead, it appears that the exercise of market power in the presence of insurance is the dominant driver of high prices. Interpretation Insurers need to re-examine how they address high-priced drugs.

Purpose: To investigate the total current curative expenditure (CCE) of lung cancer in Hunan Province, China under the framework of the System of Health Accounts 2011 (SHA 2011) and explore the effect of insurance status, surgery and length of stay on the hospitalization expenses of patients with lung cancer. Methods: Through multistage stratified cluster random sampling, a total of 46,214 patients with lung cancer were enrolled from 1,072 medical institutions in Hunan Province in 2016. Under the SHA 2011 framework, the lung cancer CCE was analyzed. The relationships between hospitalization expenditure and the following factors (surgery, type of hospital, insurance status, length of stay, institution level, age and sex) were analyzed using Spearman's correlation analyses, and how these factors influenced hospital expenditure was explored through multiple stepwise regression analysis and structural equation modelling. Results: The CCE for lung cancer patients was 8063.75 million CNY. In total, 96.03% of the CCE for lung cancer occurred in hospitals and 58.88% of the expenditure flowed to general hospitals. The highest expenditures were incurred in the group aged 55-74 y, which accounted for 61.58% of the CCE. Drugs accounted for the greatest share expenditure to lung cancer patients at 34.31% of the CCE. Surgery, insurance status, institution level, sex and hospital type explained 57.5% of the variance in hospital expenses. The hospitalization expenses were related to surgery, insurance status, institution level and sex (rs = 0.033-0.688, p < 0.001). Surgery, insurance status and length of stay had direct effects on hospitalization expenses. Length of stay mediated the relationship between surgery and hospitalization expenses for lung cancer patients. Surgery mediated the relationship between insurance status and hospitalization expenses. All of these variables can explain 45% of the variance in hospitalization expenses. Conclusions: The CCE of lung cancer is extremely high. The problems related to treatment efficiency and equity are serious for lung cancer patients in China. It is essential to expand health insurance coverage and reduce the curative expenditure of lung cancer.

This retrospective matched-cohort analysis compared health-economic burdens of adults (≥18 years; n = 377) with phenylketonuria (PKU) and age/gender-matched non-PKU controls (n = 3770) in Germany. Healthcare costs and resource-utilization were analyzed for the year 2015. Differences between groups were tested using 95% CI of mean differences (MD). PKU patients had significantly higher mean costs in total (MD €3307, 95% CI €1736–€4879), for pharmaceuticals (MD €1912, 95% CI €1195–€2629) [including dietary amino-acid supplements (MD €1268, 95% CI €864–€1672)], and outpatient costs (MD €395, 95% CI €115–€675). Inpatient costs (MD €904, 95% CI -€293 to €2100) and costs for aids and remedies (MD €97, 95% CI -€10 to €203) were also higher in PKU patients. PKU patients had more outpatient visits and stayed longer in hospital. Adult PKU patients incur higher total healthcare costs than non-PKU controls, especially regarding pharmaceuticals and outpatient costs, and more frequent resource-utilization, resulting in higher health-economic burden for the statutory healthcare system.

Background The issuing of regulation schemes and the expanding health insurance coverage for virtual visits of internet hospitals would incentivize Chinese providers and patients to use virtual visits tremendously. China’s internet hospitals vary in sponsorship. However, little is known about patients’ intention to use virtual visits delivered by different sponsorship types of internet hospitals. Objective The goal of the research is to examine patients’ intention to use virtual visits, as well as virtual visits delivered by different sponsorship types of internet hospitals. In addition, we will identify determinants of patients’ intention to use virtual visits, as well as intention to use virtual visits delivered by different sponsorship types of internet hospitals. Methods A cross-sectional survey of 1653 participants was conducted in 3-tier hospitals in 3 cities with different income levels in May and June 2019. Binary logistic regression analysis was used to identify the factors that affect patients’ intention to use virtual visits. Multinomial logistic regression analysis was conducted to identify the determinants of the intention to use virtual visits delivered by different sponsorship types of internet hospitals (ie, enterprise-sponsored, hospital-sponsored, and government-sponsored). Results A total of 76.64% (1145/1494) of adult participants were online medical information seekers, and 87.06% (969/1113) of online medical information seekers had intention to use virtual visits. Public hospital–sponsored internet hospitals were the most prevalent ones among Chinese patients (473/894, 52.9%), followed by the provincial government internet hospital platform (238/894, 26.6%), digital health companies (116/894, 13.0%), medical e-commerce companies (48/894, 5.4%), private hospitals (13/894, 1.5%), and other companies (6/894, 0.7%). Gender, education, monthly income, and consumer type were significantly associated with the intention to use virtual visits. Gender, age, education, city income level, consumer type, and trust in the sponsor of a health website were significantly associated with the patient’s intention to use virtual visits delivered by 3 different sponsorship types of internet hospitals. Conclusions Chinese patients who were online medical information seekers had high intention to use virtual visits and had different intentions to use virtual visits delivered by different sponsorship types of internet hospitals. Public hospitals, the government, and digital health companies were the top 3 sponsorship types of internet hospitals that patients had intention to use. Trust in a health website sponsor significantly influenced the patient’s intention to use virtual visits delivered by different sponsorship types of internet hospitals. Gender, education, and consumer type were the factors significantly associated with both the intention to use virtual visits and the intention to use virtual visits delivered by different sponsorship types of internet hospitals.

Background: Severe asymptomatic hypertension (SAH) is associated with significant health cost, morbidity and mortality. Aim: Establish the nationwide prevalence, trends and associated sociodemographic characteristics of SAH among patients with hypertension in the USA. Methods: We utilized the National Health and Nutrition Examination data collected over five survey cycles (2007–2016). Included were participants aged 20–80 years with self-reported diagnosis of hypertension. SAH was defined as having a mean systolic blood pressure (SBP) ≥180 mmHg and/or mean diastolic blood pressure (DBP) ≥120 mmHg at the time of examination. The Chi square test was used to compare prevalence across different categories. Associations between sociodemographic variables and SAH were assessed using multivariate binary logistic regression. Results: The prevalence of SAH among patients with hypertension is 2.15% (95% CI 1.80–2.56), mainly explained by isolated mean SBP≥180 mmHg (86% of all cases), with no statistically significant change between 2007: 2.66% (95% CI 2.10–3.36) and 2016:2.61% [95% CI 1.73–3.94), p-trend = 0.17. Increasing age (OR 1.07, 95% CI 1.04–1.09), NH Blacks (OR 2.20, 95% CI 1.37–3.54), BMI< 25 (OR 2.52, 95% CI 1.48–4.28), lack of health insurance OR 4.92% (95% CI 2.53–9.54) and never married individuals (OR = 2.59%, 95% CI 1.20–5.60) were more likely to have SAH, comparatively. There was no significant association between duration of hypertension and SAH. Conclusion: The prevalence of SAH in the USA is 2.15% and has been stable over the past decade. Our study underscores the importance of identifying barriers to screening and treatment of hypertension which is a major treatable risk factor for cardiovascular disease.

BackgroundAlthough apps are increasingly being used to support the diagnosis, treatment and management of mental illness, there is no single means through which costs associated with mental apps are being reimbursed. Furthermore, different apps are amenable to different means of reimbursement as not all apps generate value in the same way.AimsTo provide insights into how apps are currently generating value and being reimbursed across the world, with a particular focus on the situation in the USA.MethodAn international team performed secondary research on how apps are being used and on common pathways to remuneration.ResultsThe uses of apps today and in the future are reviewed, the nature of the value delivered by apps is summarised and an overview of app reimbursement in the USA and other countries is provided. Recommendations regarding how payments might be made for apps in the future are discussed.ConclusionsCurrently, apps are being reimbursed through channels with other original purposes. There may be a need to develop an app-specific channel for reimbursement which is analogous to the channels used for devices, drugs and laboratory tests.

Background Fraud, Waste, and Abuse (FWA) detection is a significant yet challenging problem in the health insurance industry. An essential step in FWA detection is to check whether the medication is clinically reasonable with respect to the diagnosis. Currently, human experts with sufficient medical knowledge are required to perform this task. To reduce the cost, insurance inspectors tend to build an intelligent system to detect suspicious claims with inappropriate diagnoses/medications automatically. Objective The aim of this study was to develop an automated method for making use of a medical knowledge graph to identify clinically suspected claims for FWA detection. Methods First, we identified the medical knowledge that is required to assess the clinical rationality of the claims. We then searched for data sources that contain information to build such knowledge. In this study, we focused on Chinese medical knowledge. Second, we constructed a medical knowledge graph using unstructured knowledge. We used a deep learning–based method to extract the entities and relationships from the knowledge sources and developed a multilevel similarity matching approach to conduct the entity linking. To guarantee the quality of the medical knowledge graph, we involved human experts to review the entity and relationships with lower confidence. These reviewed results could be used to further improve the machine-learning models. Finally, we developed the rules to identify the suspected claims by reasoning according to the medical knowledge graph. Results We collected 185,796 drug labels from the China Food and Drug Administration, 3390 types of disease information from medical textbooks (eg, symptoms, diagnosis, treatment, and prognosis), and information from 5272 examinations as the knowledge sources. The final medical knowledge graph includes 1,616,549 nodes and 5,963,444 edges. We designed three knowledge graph reasoning rules to identify three kinds of inappropriate diagnosis/medications. The experimental results showed that the medical knowledge graph helps to detect 70% of the suspected claims. Conclusions The medical knowledge graph–based method successfully identified suspected cases of FWA (such as fraud diagnosis, excess prescription, and irrational prescription) from the claim documents, which helped to improve the efficiency of claim processing.

Radiotherapy (RT) is one of the primary cancer treatment modalities. To estimate the actual utilization of RT and infrastructure in Korea, the current study was performed. Data from 2012 to 2016 were extracted from the Health Insurance Review and Assessment Service. In addition, a nationwide survey was conducted to collect the statistics of RT facilities, equipment and human resources in Korea. The total number of patients treated with RT was 72 563 in 2016. The five cancers that were most commonly treated with RT in 2016 were breast, lung, colorectal, liver and prostate cancer. According to analyses of specific treatment modalities, the number of patients treated with intensity-modulated radiotherapy (IMRT), stereotactic radiation therapy (SRT) and proton therapy increased from 6670, 6306 and 50 in 2012 to 21584, 9048 and 703 in 2016, respectively. Ninety radiation oncology centers were working in 2015 and there were a total of 213 megavoltage teletherapy machines. In 2015, 310 patients were treated per megavoltage RT machine, 246 patients per radiation oncologist, 501 patients per medical physicist and 111 patients per radiotherapy technologist. In conclusion, the number of patients who underwent RT in Korea has increased steadily from 2012 to 2016. The IMRT utilization rate remarkably increased in 2016, and the number of patients treated with advanced treatment modalities such as IMRT, SRT and proton therapy is expected to increase.

As part of a regulatory commitment for post-licensure safety monitoring of live, oral human rotavirus vaccine (RV1), this study compared the incidence rates (IR) of intussusception, acute lower respiratory tract infection (LRTI) hospitalization, Kawasaki disease, convulsion, and mortality in RV1 recipients versus inactivated poliovirus vaccine (IPV) recipients in concurrent (cIPV) and recent historical (hIPV) comparison cohorts. Vaccine recipients were identified in 2 claims databases from August 2008 – June 2013 (RV1 and cIPV) and January 2004 – July 2008 (hIPV). Outcomes were identified in the 0–59 days following the first 2 vaccine doses. Intussusception, Kawasaki disease, and convulsion were confirmed via medical record review. Outcome IRs were estimated. Incidence rate ratios (IRRs) were obtained from Poisson regression models. A post-hoc self-controlled case series (SCCS) analysis compared convulsion IRs in a 0–7 day post-vaccination period to a 15–30 day post-vaccination period. We identified 57,931 RV1, 173,384 cIPV, and 159,344 hIPV recipients. No increased risks for intussusception, LRTI, Kawasaki disease, or mortality were observed. The convulsion IRRs were elevated following RV1 Dose 1 (cIPV: 2.07, 95% confidence interval [CI]: 1.27 – 3.38; hIPV: 2.05, 95% CI: 1.24 – 3.38), a finding which is inconclusive as it was observed in only one of the claims databases. The IRR following RV1 Dose 1 in the SCCS analysis lacked precision (2.40, 95% CI: 0.73 – 7.86). No increased convulsion risk was observed following RV1 Dose 2. Overall, this study supports the favorable safety profile of RV1. Continued monitoring for safety signals through routine surveillance is needed to ensure vaccine safety.

// Jennifer Muigai 1 , Louis Jacob 2 , Konstantinos Dinas 3 , Karel Kostev 1, 4 and Matthias Kalder 1 1 Department of Gynecology and Obstetrics, Philipps-University Marburg, Marburg, Germany 2 Faculty of Medicine, University of Paris 5, Paris, France 3 Aristotle University of Thessaloniki, Faculty of Medicine, Thessaloniki, Greece 4 Epidemiology, QuintilesIMS, Frankfurt am Main, Germany Correspondence to: Karel Kostev, email: karel.kostev@gmx.de Keywords: vulvar cancer; delay; risk factors; vulva infection; vulva inflammation Received: August 15, 2017 Accepted: November 05, 2017 Published: January 03, 2018 ABSTRACT The goal of this study was to estimate a potential delay in the diagnosis of vulvar cancer and identify associated risk factors in women treated in gynecological practices in Germany. The current study sample included 1,652 women from 218 gynecological practices who received an initial diagnosis of vulvar cancer (ICD 10: C51) between January 2000 and December 2015 (index date). After applying several exclusion criteria, 505 non-cancer controls were matched (1:1) to 505 vulvar cancer cases based on age, health insurance status, and index date. The primary outcome was the delay in vulvar cancer diagnosis in women who had received an initial diagnosis of diseases of Bartholin's gland, inflammation of vagina and vulva, or other specified noninflammatory disorders of vulva, including atrophy, hypertrophy, and cyst. A logistic regression model was used to estimate the association between vulvar cancer and pre-defined diagnoses. The mean age was 60.8 years (SD = 15.6 years), and 4.8% of women had private health insurance coverage. Inflammation of vagina and vulva was diagnosed 328 days (SD = 95 days) prior to the detection of vulvar cancer. This delay was 186 days (SD = 196 days) in patients affected by diseases of Bartholin’s gland and 300 days (SD = 116 days) in those with other specified noninflammatory disorders of vulva including atrophy, hypertrophy, and cyst. The risk of vulvar cancer was positively associated with inflammation of vagina and vulva (OR = 2.28) and other specified noninflammatory disorders of vulva (OR = 5.39). The mean potential delay of vulvar cancer diagnosis ranged from 186 to 328 days.

Purpose Our objective was to evaluate the utility of the national database (NDB) based on health insurance claims data for antimicrobial use (AMU) surveillance in medical institutions in Japan. Methods The population-weighted total AMU expressed as defined daily doses (DDDs) per 1000 inhabitants per day (DID) was measured by the NDB. The data were compared with our previous study measured by the sales data. Trend analysis of DID from 2011 to 2013 and subgroup analysis stratified by antimicrobial category and age group were performed. Results There was a significant linear correlation between the AMUs measured by the sales data and the NDB. Total oral and parenteral AMUs (expressed in DID) were 1.04-fold from 12.654 in 2011 to 13.202 in 2013 and 1.13-fold from 0.734 to 0.829, respectively. Percentage of oral form among total AMU was high with more than 94% during the study period. AMU in the children group (0–14 years) decreased from 2011 to 2013 regardless of dosage form, although the working age group (15–64 years) and elderly group (65 and above years) increased. Oral AMU in the working age group was approximately two-thirds of those in the other age groups. In contrast, parenteral AMU in the elderly group was extremely high compared to the other age groups. Conclusions The trend of AMU stratified by antimicrobial category and age group were successfully measured using the NDB, which can be a tool to monitor outcome indices for the national action plan on antimicrobial resistance.

SUMMARYThis study evaluated the annual prevalence of anogenital warts (AGW) caused by human papillomavirus (HPV) and analysed the trend in annual per cent changes (APC) by using national claims data from the Health Insurance Review and Assessment of Korea, 2007–2015. We also estimated the socio-economic burden and co-morbidities of AGW. All analyses were performed based on data for primary A63.0, the specific diagnosis code for AGW. The socio-economic cost of AGW was calculated based on the direct medical cost, direct non-medical cost and indirect cost. The overall AGW prevalence and socio-economic burden has increased during the last 9 years. However, the prevalence of AGW differed significantly by sex. The female prevalence increased until 2012, and decreased thereafter (APC + 3·6%). It would fall after the introduction of routine HPV vaccination, principally for females, in Korea. The male prevalence increased continuously over time (APC + 11·6%), especially in those aged 20–49 years. Referring to the increasing AGW prevalence and its disease burden, active HPV infection control surveillance and prevention in males are worth consideration.

ObjectiveAccording to the US Affordable Care Act, restaurant chains are required to provide energy (calorie) and other nutrition information on their menu. The current study examined the impact of menu labelling containing calorie information and recommended daily calorie intake, along with subjective nutrition knowledge, on intention to select lower-calorie foods prior to the implementation of the Affordable Care Act.DesignFull factorial experimental design with participants exposed to four variants of a sample menu in a 2 (presence v. absence of calorie information) ×2 (presence v. absence of recommended daily calorie intake).SettingLarge, public university in the Southwest USA.SubjectsPrimarily undergraduate college students.ResultsMajority of participants were 19–23 years of age (mean 21·8 (sd 3·6) years). Menu information about calorie content and respondents’ subjective nutrition knowledge had a significantly positive impact on students’ intention to select lower-calorie foods (β=0·24, Pβ=0·33, Pβ=0·10, P=0·105). Gender played a significant role on purchase intent for lower-calorie menu items, with females more affected by the calorie information than males (β=0·37, PConclusionsFindings support the role menu labelling can play in encouraging a healthier lifestyle for college students. College students who are Generation Y desire healthier menu options and accept nutritional labels on restaurant menus as a way to easily and expediently obtain nutrition information.

Background Insurance organizations are essential stakeholders in health care ecosystems. For addressing future health care needs, insurance companies require access to health data to deliver preventative and proactive digital health services to customers. However, extant research is limited in examining the conditions that incentivize health data sharing. Objective This study aimed to (1) identify the expectations of insurance customers when sharing health data, (2) determine the perceived intrinsic value of health data, and (3) explore the conditions that aid in incentivizing health data sharing in the relationship between an insurance organization and its customer. Methods A Web-based survey was distributed to randomly selected customers from a Finnish insurance organization through email. A single open-text answer was used for a qualitative data analysis through inductive coding, followed by a thematic analysis. Furthermore, the 4 constructs of commitment, power, reciprocity, and trust from the social exchange theory (SET) were applied as a framework. Results From the 5000 customers invited to participate, we received 452 surveys (response rate: 9.0%). Customer characteristics were found to reflect customer demographics. Of the 452 surveys, 48 (10.6%) open-text responses were skipped by the customer, 57 (12.6%) customers had no expectations from sharing health data, and 44 (9.7%) customers preferred to abstain from a data sharing relationship. Using the SET framework, we found that customers expected different conditions to be fulfilled by their insurance provider based on the commitment, power, reciprocity, and trust constructs. Of the 452 customers who completed the surveys, 64 (14.2%) customers required that the insurance organization meets their data treatment expectations (commitment). Overall, 4.9% (22/452) of customers were concerned about their health data being used against them to profile their health, to increase insurance prices, or to deny health insurance claims (power). A total of 28.5% (129/452) of customers expected some form of benefit, such as personalized digital health services, and 29.9% (135/452) of customers expected finance-related compensation (reciprocity). Furthermore, 7.5% (34/452) of customers expected some form of empathy from the insurance organization through enhanced transparency or an emotional connection (trust). Conclusions To aid in the design and development of digital health services, insurance organizations need to address the customers’ expectations when sharing their health data. We established the expectations of customers in the social exchange of health data and explored the perceived values of data as intangible goods. Actions by the insurance organization should aim to increase trust through a culture of transparency, commitment to treat health data in a prescribed manner, provide reciprocal benefits through digital health services that customers deem valuable, and assuage fears of health data being used to prevent providing insurance coverage or increase costs.

Poor compliance with existing guidelines for tuberculosis (TB) care and treatment is an issue of concern in China. We assessed health service use by TB patients over the entire treatment process and compared it to the recommended guidelines.We collected insurance claims data in three counties of one province of Eastern China. Patient records with a diagnosis of 'pulmonary TB' in 2015 and 2016 were extracted. Treatment duration, number of outpatient (OP) visits and hospital admissions, as well as total cost, out-of-pocket (OOP) payments and effective reimbursement rates were analysed.A total of 1394 patients were included in the analysis. More than 48% received over the 8 months of treatment that TB guidelines recommend, and over 28% received less. 49% of Urban and Rural Resident Basic Medical Insurance (URRBMI) TB patients were hospitalised while 30% of those with Urban Employee Basic Medical Insurance (UEBMI) had at least one admission. Median total cost for patients with hospital admission was almost 10 times that of patients without. By comparison, the average OOP was 5 times higher. UEBMI patients had a shorter treatment period, more outpatient visits but considerably fewer hospital admissions than URRBMI patients.We found an alarming extent of TB over- and under-treatment in our study population. There is an urgent need to improve compliance with treatment guidelines in China and to better understand the drivers of divergence. Extending the coverage of health insurance schemes and increasing reimbursement rates for TB outpatient services would seem to be key factors in reducing both the overall cost and financial burden on patients.Le mauvais respect des directives existantes en matière de soins et de traitement de la tuberculose (TB) est un sujet préoccupant en Chine. Nous avons évalué l'utilisation des services de santé par les patients TB tout au long du processus de traitement et l'avons comparée aux directives recommandées. MÉTHODES: Nous avons collecté des données sur les réclamations d'assurance dans trois comtés d'une province de l'est de la Chine. Les dossiers de patients avec un diagnostic de «TB pulmonaire» en 2015 et 2016 ont été extraits. La durée du traitement, le nombre de visites ambulatoires et d'hospitalisations, ainsi que le coût total, les paiements directs et les taux de remboursement effectifs ont été analysés. RÉSULTATS: 1.394 patients ont été inclus dans l'analyse. Plus de 48% ont reçu plus de 8 mois du traitement recommandé par les directives TB et plus de 28% en ont reçu moins. 49% des patients TB résidents urbains et ruraux de l'assurance médicale de base (URRBMI) ont été hospitalisés, tandis que 30% de ceux avec une assurance médicale de base des employés urbains (UEBMI) ont eu au moins une admission. Le coût total moyen pour les patients hospitalisés était près de 10 fois plus élevé que celui des patients non hospitalisés. En comparaison, le payement direct moyen était 5 fois plus élevé. Les patients UEBMI ont eu une période de traitement plus courte, plus de visites ambulatoires mais beaucoup moins d'hospitalisations que les patients URRBMI.Nous avons trouvé une étendue alarmante de sur- et sous-traitement de la TB dans notre population d’étude. Il est urgent d'améliorer le respect des directives de traitement en Chine et de mieux comprendre les facteurs de divergence. L'extension de la couverture des schémas d'assurance santé et l'augmentation des taux de remboursement des services ambulatoires pour la TB sembleraient être des facteurs essentiels pour réduire à la fois le coût global et la charge financière pour les patients.

Cellulitis is a common infection of the skin and soft tissue. Susceptibility to cellulitis is related to microorganism virulence, the host immunity status and environmental factors. This retrospective study from 2001 to 2013 investigated relationships between the monthly incidence rate of cellulitis and meteorological factors using data from the Taiwanese Health Insurance Dataset and the Taiwanese Central Weather Bureau. Meteorological data included temperature, hours of sunshine, relative humidity, total rainfall and total number of rainy days. In otal, 195 841 patients were diagnosed with cellulitis and the incidence rate was strongly correlated with temperature (γS = 0.84, P < 0.001), total sunshine hours (γS = 0.65, P < 0.001) and total rainfall (γS = 0.53, P < 0.001). The incidence rate of cellulitis increased by 3.47/100 000 cases for every 1° elevation in environmental temperature. Our results may assist clinicians in educating the public of the increased risk of cellulitis during warm seasons and possible predisposing environmental factors for infection.

The paper focus on secondary prevention (diagnostic screening, medical examination, checks-up…) which refers to the early detection of disease. In particular secondary prevention in analyzed as an instrument of self-insurance: if illness occurs, the negative health shock decrease. Both the case in which secondary prevention and treatment are complementary goods, and that in which they are substitutes, are analyzed. Optimal reimbursement for prevention and treatment is derived when insurance uses a liner mechanism. Results show that, starting from a situation with no insurance, a linear contract always encourages treatment consumption whereas it may either encourage or discourage secondary prevention consumption. Prevention consumption is discouraged when the two goods are substitutes. In the former case, one of the two goods is taxed and the other is subsidized, while in the latter case the two goods are either both subsidized or taxed.

Background Noncommunicable disease (NCD) risk factors increase the risk of adverse reproductive health outcomes and are becoming increasingly common in Brazil. Methods We analyzed VIGITEL 2011 telephone survey data for 13,745 Brazilian women aged 18–44 years in a probabilistic sample from 26 Brazilian state capitals and the Federal District. We examined associations between NCD risk factors (fruit and vegetable intake, leisure time physical activity, alcohol consumption, smoking status, BMI and hypertension status) and race, education, and insurance using chi-square tests and multivariable logistic regression models, estimating the average marginal effects to produce adjusted relative risk ratios (aRRs). Analyses were conducted using SAS 9.3 survey procedures and weighted to reflect population estimates. Results Women with less than a college education were more likely to report physical inactivity (adjusted relative risk (aRR) and 95% confidence interval = 1.1 (1.1–1.2)), smoking (aRR = 1.7 (1.3–2.2)), and self-reported diagnoses of hypertension (aRR = 2.0 (1.6–2.5)) compared to women with a college education or greater. Similarly, women without health insurance were more likely to report physical inactivity (aRR = 1.1 (1.1–1.2)), smoking (aRR = 1.4 (1.1–1.8)), and self-reported diagnoses of hypertension aRR = 1.4 (1.1–1.7)) compared to women with health insurance. Less variation was found by race and NCD risk factors. Conclusion Targeted public health strategies and policies are needed to increase healthcare access and decrease educational and racial disparities in NCD risk factors among women of reproductive age in Brazil., Highlights • Examine prevalence of NCD risk factors with race, education, and insurance status • We analyzed data from a probabilistic sample of 13,745 non-pregnant Brazilian women. • Less educated women reported more physical inactivity, smoking, and hypertension. • Uninsured women reported more physical inactivity, smoking and hypertension. • Less variation was found by race and noncommunicable disease risk factors.

Background: The treatment of congenital heart disease patients in the West Bank and Gaza involves both medical and political challenges. To better understand these challenges' effects on Palestinian patients, we compared surgical results between Israeli and Palestinian patients. Understanding the difficulties faced in treating the Palestinian population is an important step to improving surgical care, better allocating resources and overcoming the region's unique problems. Methods: We retrospectively reviewed the Hadassah Medical Center congenital heart disease database. Between January 2011 and December 2017, there were 872 operations performed in patients with Israeli health insurance and 207 operations in Palestinian patients. Demographics, clinical characteristics, surgical complexities, time to treatment, PICU length of stay, hospital length of stay, mortality and follow-up rates were compared between the two groups using standard statistical practices. Findings: The surgical complexity was significantly higher in the Palestinian patient population (p=0.003) and there were relatively more Palestinian patients with single ventricle anatomy (25.6%, 53/207) than Israeli patients (19.8%, 172/872) p=0.067. Israeli neonates had surgery at an average age of 9.5±7.8 days as compared to Palestinian neonates with an average age of 15.7±8.2 days, p

The goal of Seguro Popular (SP) in Mexico was to improve the financial protection of the uninsured population against excessive health expenditures. This paper estimates the impact of SP on catastrophic health expenditures (CHE), as well as out-of-pocket (OOP) health expenditures, from two different sources. First, we use the SP Impact Evaluation Survey (2005–2006), and compare the instrumental variables (IV) results with the experimental benchmark. Then, we use the same IV methods with the National Health and Nutrition Survey (ENSANUT 2006). We estimate naïve models, assuming exogeneity, and contrast them with IV models that take advantage of the specific SP implementation mechanisms for identification. The IV models estimated included two-stage least squares (2SLS), bivariate probit, and two-stage residual inclusion (2SRI) models. Instrumental variables estimates resulted in comparable estimates against the “gold standard.” Instrumental variables estimates indicate a reduction of 54% in catastrophic expenditures at the national level. SP beneficiaries also had lower expenditures on outpatient and medicine expenditures. The selection-corrected protective effect is found not only in the limited experimental dataset, but also at the national level.

Background: Reductions in health insurance enrollment outreach could have negative effects on the individual health insurance market. Specifically, consumers may not be informed about the availability of coverage, and if some healthier consumers fail to enroll, there could be a worse risk pool for insurers. Kentucky created its own Marketplace, known as kynect, and adopted Medicaid expansion under the Affordable Care Act, which yielded the largest decline in adult uninsured rate in the United States from 2013 to 2016. The state sponsored an award-winning media campaign, yet after the election of a new governor in 2015, it declined to renew the television advertising contract for kynect and canceled all pending television ads with over a month remaining in the 2016 open enrollment period. Objective: The objective of this study is to examine the stark variation in television advertising across multiple open enrollment periods in Kentucky and use this variation to estimate the dose-response effect of state-sponsored television advertising on consumer engagement with the Marketplace. In addition, we assess to what extent private insurers can potentially help fill the void when governments reduce or eliminate television advertising. Methods: We obtained television advertising (Kantar Media/Campaign Media Analysis Group) and Marketplace data (Kentucky Health Benefit Exchange) for the period of October 1, 2013, through January 31, 2016, for Kentucky. Advertising data at the spot level were collapsed to state-week counts by sponsor type. Similarly, a state-week series of Marketplace engagement and enrollment measures were derived from state reports to Centers for Medicare and Medicaid Services. We used linear regression models to estimate associations between health insurance television advertising volume and measures of information-seeking (calls to call center; page views, visits, and unique visitors to the website) and enrollment (Web-based and total applications, Marketplace enrollment). Results: We found significant dose-response effects of weekly state-sponsored television advertising volume during open enrollment on information-seeking behavior (marginal effects of an additional ad airing per week for website page views: 7973, visits: 390, and unique visitors: 388) and enrollment activity (applications, Web-based: 61 and total: 56). Conclusions: State-sponsored television advertising was associated with nearly 40% of unique visitors and Web-based applications. Insurance company television advertising was not a significant driver of engagement, an important consideration if cuts to government-sponsored advertising persist.

Objective To determine whether increased cost sharing in health insurance plans induces higher levels of consumer sophistication in a non-elderly population. Study design This analysis is based on the collection of survey and demographic data collected from enrollees in the RAND health insurance experiment (HIE). During the RAND HIE, enrollees were randomly assigned to different levels of cost sharing (0, 25, 50 and 95%). Methods The study population compromises about 2000 people enrolled in the RAND HIE, between the years 1974 and 1982. Effects on health-care decision making were measured using the results of a standardized questionnaire, administered at the beginning and end of the experiment. Points of enquiry included whether or not enrollees' (i) recognized the need for second opinions (ii) questioned the effectiveness of certain therapies and (iii) researched the background/skill of their medical providers. Consumer sophistication was also measured for regular health-care consumers, as indicated by the presence of a chronic disease. Principal findings We found no statically significant changes (P

SUMMARYBecause sentinel surveillance systems cannot obtain information about patients who visit non-sentinel medical facilities, the characteristics of patients identified by these systems may be biased. In this study, we evaluated the representativeness of a methicillin-resistant Staphylococcus aureus (MRSA) surveillance system using health insurance claim (HIC) data, which does not depend on physician notification. We calculated the age-specific incidence of MRSA patients using data from the Japan Nosocomial Infections Surveillance (JANIS) programme, which is based on sentinel surveillance systems, and inpatient HICs submitted to employee health insurance organizations in 2011, and then computed age-specific incidence ratios between the HIC and JANIS data. Age-specific MRSA incidence in both datasets followed J-shaped curves with similar shapes. For all age groups, the ratios between HIC and JANIS data were around 10. These findings indicate that JANIS notification of MRSA cases was not affected by patients’ age.

The recently published S2k-guideline on (allergen-) specific immunotherapy (AIT) provides an excellent overview of the evidence on allergen preparations available for AIT in Germany based on the published efficacy studies. Publications based on the guideline are currently being used by the German associations of statutory health insurance physicians and German health insurance funds to open a discussion on the reimbursement status of allergen preparations. In our view, calling the reimbursement status of perscribable and tradable AIT preparations into question on the basis of an assessment of the current body of evidence in the guideline is to be rigidly opposed. In Germany the Paul Ehrlich Institute (PEI) is the only authority empowered to decide on the marketability of AIT preparations, and decisions on the reimbursement status of AIT products need to be based on cost-benefit analyses and not solely on an evaluation of the evidence. The present article aims to examine the relationship between the evidence, efficacy, tradability, and reimbursability of AIT preparations.

Background: Having health insurance is associated with a number of beneficial health outcomes. However, previous research suggests that patients tend to avoid health insurance information and often misunderstand or lack knowledge about many health insurance terms. Health insurance knowledge is particularly low among young adults. Objective: The purpose of this study was to design and test an interactive newsgame (newsgames are games that apply journalistic principles in their creation, for example, gathering stories to immerse the player in narratives) about health insurance. This game included entry-level information through scenarios and was designed through the collation of national news stories, local personal accounts, and health insurance company information. Methods: A total of 72 (N=72) participants completed in-person, individual gaming sessions. Participants completed a survey before and after game play. Results: Participants indicated a greater self-reported understanding of how to use health insurance from pre- (mean=3.38, SD=0.98) to postgame play (mean=3.76, SD=0.76); t71=−3.56, P=.001. For all health insurance terms, participants self-reported a greater understanding following game play. Finally, participants provided a greater number of correct definitions for terms after playing the game, (mean=3.91, SD=2.15) than they did before game play (mean=2.59, SD=1.68); t31=−3.61, P=.001. Significant differences from pre- to postgame play differed by health insurance term. Conclusions: A game is a practical solution to a difficult health issue—the game can be played anywhere, including on a mobile device, is interactive and will thus engage an apathetic audience, and is cost-efficient in its execution. [JMIR Serious Games 2017;5(4):e22]

Background: The German transplantation system is in a crisis due to a lack of donor organs. Information campaigns are one of the main approaches to increase organ donation rates. Since 2012, German health insurance funds are obliged by law to inform their members about organ donation. We raised the hypothesis: The willingness to sign a donor card rises due to the subsequent increase of specific knowledge by receiving the information material of the health insurance funds. Objective: The objective of the study was to assess the influence of information campaigns on the specific knowledge and the willingness to donate organs. Methods: We conducted an online survey based on recruitment via Facebook groups, advertisements using the snowball effect, and on mailing lists of medical faculties in Germany. Besides the demographic data, the willingness to hold an organ donor card was investigated. Specific knowledge regarding transplantation was explored using five factual questions resulting in a specific knowledge score. Results: We recruited a total of 2484 participants, of which 32.7% (300/917) had received information material. Mean age was 29.9 (SD 11.0, median 26.0). There were 65.81% (1594/2422) of the participants that were female. The mean knowledge score was 3.28 of a possible 5.00 (SD 1.1, median 3.0). Holding a donor card was associated with specific knowledge ( P

Aim: To examine how household expenditure on food at restaurants, alcohol, gambling and insurance vary between smoking and non-smoking households. Design: Cross sectional survey of households from private dwellings, conducted by the Australian Bureau of Statistics (ABS), using a stratified multistage area sample design. Setting: Australia, 1998–99. Participants: Nationally representative sample of households (n = 6892). Main outcome measures: Expenditure on meals at restaurants, alcohol, alcoholic beverages at licensed premises, gambling, and insurance. Results: The odds of reporting expenditure on restaurant food and health insurance were 20% and 40% smaller for smoking than non-smoking households, respectively. The odds of reporting expenditure on alcohol (not including expenditure at licensed premises), drinking at licensed premises, and gambling were 100%, 50%, and 40% greater for smoking than for non-smoking households, respectively. Conclusions: The study suggests that smokers are more likely to engage in risky behaviour. Implementing smoking bans in licensed premises and gambling venues can provide an opportunity to reduce smoking prevalence. Quitting or cutting down smoking can provide opportunities for expenditure on other products or services, and enhance standards of living.

We investigate whether people enrolled into voluntary health insurance (VHI) substitute public consumption with private (opt out) or just enlarge their private consumption, without reducing reliance upon public provisions (top up). We study the case of Italy, where a mixed insurance system is in place. To this purpose, we specify a joint model for public and private specialist visits counts, and allow for different degrees of endogenous supplementary insurance coverage, looking at the insurance coverage as driven by a trinomial choice process. We disentangle the effect of income and wealth by going through two channels: the direct impact on the demand for healthcare and that due to selection into VHI. We find evidence of opting out: richer and wealthier individuals consume more private services and concomitantly reduce those services publicly provided through selection into for-profit VHI. These results imply that the market for VHI eases the redistribution from high income (doubly insured) individuals to low income (not doubly insured) ones operated by the Italian National Health Service (NHS). Accounting for VHI endogeneity in the joint model of the two counts is crucial to this conclusion.

This study was undertaken to examine the characteristics of cancers detected at the earliest possible point on MRI and to determine their significance.This institutional review board-approved Health Insurance Portability and Accountability Act-compliant retrospective study evaluated invasive breast cancers ≤1 cm histologically. MRI was performed within 6 months before diagnosis. Between 1 January 2005 and 31 December 2015, 163 cancers in 161 patients were evaluated. Breast Imaging-Reporting and Data System lesion characteristics were assessed by two radiologists independently. In cases of disagreement, arbitration by a third reader was performed.Cancers ≤1 cm became more obviously malignant as they enlarged with regard to shape (p = 0.021), margin (p = 0.0006), internal enhancement (p = 0.0158) and kinetics (p = 0.0001). Cancers ≤5 mm had benign characteristics of circumscribed margins in 71% (71/100), round/oval shape in 67% (67/100) and persistent enhancement in 41% (41/100). High TBenign characteristics are present in most invasive cancers ≤5 mm. Small cancers on MRI may need to demonstrate growth to determine need for biopsy. Advances in knowledge: MR lesion characteristics may not be helpful in determining whether small lesions on MR are benign or malignant. However, as 97% of cancers in our study showed interval change when a prior MR for comparison was available, new lesions or increasing size should lead to consideration of biopsy.

To describe the multimodality imaging features, metastatic pattern and clinical outcome in adult extraskeletal Ewing sarcoma (EES).In this institutional review board-approved, health insurance portability and accountability act-compliant retrospective study, we included 26 patients (17 females and 9 males; mean age, 36 years; range, 18-85 years) with pathologically confirmed EES seen at our institute between 1999 and 2011, who had imaging of primary tumour. Imaging of primary tumour in all 26 patients and follow-up imaging in 23 was reviewed by two radiologists in consensus. Clinical data were extracted from electronic medical records.The most common primary sites were the torso (n = 13), extremities (n = 10) and head and neck (HN) region (n = 3). The mean tumour size was 9 cm (range, 3-22 cm); tumours of the torso were larger than those of other areas (p0.05). Compared with the skeletal muscle, tumours were isodense on CT (21/21), hypointense (n = 5) to isointense (n = 14) on T1 weighted image, hyperintense on T2 weighted image (19/19) and were fluorine-18 fludeoxyglucose ((18)F-FDG)-avid [10/10; mean maximum standardized uptake value of 7 (range, 3-11)]. Necrosis (15/26), haemorrhage (5/26) and adjacent organ invasion (14/26) were present without calcification. Median follow-up was 16 months. 5 patients had local recurrence (torso, 3; extremity, 1; and HN, 1). Metastases developed in 11 patients (torso, 7; extremities, 3; and HN, 1; p0.05); 8 at presentation, most commonly to lung (9/11), peritoneum (4/11), muscles (4/11) and lymph nodes (4/11). Nine patients (torso, 7; extremity, 1; and HN, 1) died (10 months median survival) (p0.05).Adult EESs are large tumours, which frequently invade adjacent organs and metastasize to the lung. EESs of the torso are larger, have more frequent metastases and poorer outcomes.Adult EESs of the torso have poor outcomes compared with other EESs.

To describe imaging features of primary and metastatic alveolar soft part sarcoma (ASPS).In this institutional review board-approved and Health Insurance Portability and Accountability Act-compliant retrospective study, 25 patients (14 males; mean age, 25 years; range, 18-40 years) with pathologically proven ASPS seen at our institute between 1995 and 2013 were included. Imaging of primary tumours in 5 patients and follow-up imaging in 25 patients were reviewed by 2 radiologists in consensus. Clinical information was obtained from electronic medical records.The most common sites for the primary tumour were extremities (17/25, 68%) and torso (6/25, 24%). Primary tumours (n = 5) were well circumscribed, compared with skeletal muscle, were isodense on CT, hyperintense on T1 and T2 weighted images with intense post-contrast enhancement, prominent feeders on CT and flow voids on MRI. Metastases developed in 23/25 (92%) patients, 18 at presentation. The most common sites of metastases were the lungs (100%), lymph nodes (74%), bones (57%) and brain (43%). Visceral and nodal metastases were hypervascular. At the time of reporting the results, 15 patients have died, 6 are alive and 4 were lost to follow-up. Median survival was 74 months for those without brain metastases (n = 8) and 60 months for those with brain metastases (n = 7). Median survival was shorter for patients with metastases at presentation.ASPS most commonly involves the lower extremities of young adults, is hypervascular on imaging, often metastasizes at presentation, frequently to lung, nodes, bones and brain, and has an indolent course despite metastases. Brain metastases and high tumour burden (number of metastatic sites) at presentation decreased survival in our study.ASPS has an unusual pattern of metastases to the brain and nodes in addition to lung and bones. It has an indolent course despite metastases.

Background: There is a push towards quality measures in health care. As a consequence, the National Committee for Quality Assurance (NCQA) has been publishing insurance plan quality measures. Objective: The objective of this study was to examine the relationship between insurance plan quality measures and the participating providers (doctors). Methods: We collected and analyzed provider and insurance plan data from several online sources, including provider directories, provider referrals and awards, patient reviewing sites, and hospital rankings. The relationships between the provider attributes and the insurance plan quality measures were examined. Results: Our analysis yielded several findings: (1) there is a moderate Pearson correlation (r=.376) between consumer satisfaction insurance plan scores and review ratings of the member providers, (2) referral frequency and provider awards are negligibly correlated to consumer satisfaction plan scores (correlations of r=.031 and r=.183, respectively), (3) there is weak positive correlation (r=.266) between the cost charged for the same procedures and consumer satisfaction plan scores, and (4) there is no significant correlation between member specialists’ review ratings and specialty-specific insurance plan treatment scores for most specialties, except a surprising weak negative correlation for diabetes treatment (r=-.259). Conclusions: Our findings may be used by consumers to make informed choices about their insurance plans or by insurances to understand the relationship between patients’ satisfaction and their network of providers. [J Med Internet Res 2016;18(10):e279]

In Germany, the national routine childhood immunization schedule comprises 12 vaccinations. Primary immunizations should be completed by 24 mo of age. However, nationwide monitoring of vaccination coverage (VC) is performed only at school entry. We utilized health insurance claims data covering ~85% of the total population with the objectives to (1) assess VC of all recommended childhood vaccinations in birth-cohorts 2004-2009, (2) analyze cross-sectional (at 24 and 36 mo) and longitudinal trends, and (3) validate the method internally and externally. Counting vaccine doses in a retrospective cohort fashion, we assembled individual vaccination histories and summarized VC to nationwide figures. For most long-established vaccinations, VC at 24 mo was at moderate levels (~73-80%) and increased slightly across birth-cohorts. One dose measles VC was high (94%), but low (69%) for the second dose. VC with a full course of recently introduced varicella, pneumococcal, and meningococcal C vaccines increased across birth-cohorts from below 10% above 60%, 70%, and 80%, respectively. At 36 mo, VC had increased further by up to 15 percentage points depending on vaccination. Longitudinal analysis suggested a continued VC increase until school entry. Validation of VC figures with primary data showed an overall good agreement. In conclusion, analysis of health insurance claims data allows for the estimation of VC among children in Germany considering completeness and timeliness of vaccination series. This approach provides valid nationwide VC figures for all currently recommended pediatric vaccinations and fills the information gap between early infancy and late assessment at school entry.

Free GP care for all and a move to an insurance based rather than a taxation based funding model are among major changes to the Irish health system signalled in a white paper that the government published last week.1 The prime minister, Enda Kenny, and the minister for health, James Reilly, unveiled plans to create a one tier health system, with access based on need rather than the ability to pay. At present some 40% of the Irish population are eligible for free healthcare, based on …

BackgroundNigeria contributes only 2% to the world’s population, accounts for 10% of the global maternal death burden. Health care at primary health centers, the lowest level of public health care, is far below optimal in quality and grossly inadequate in coverage. Private primary health facilities attempt to fill this gap but at additional costs to the client. More than 65% Nigerians still pay out of pocket for health services. Meanwhile, the use of mobile phones and related services has risen geometrically in recent years in Nigeria, and their adoption into health care is an enterprise worth exploring. ObjectiveThe purpose of this study was to document costs associated with a mobile technology–supported, community-based health insurance scheme. MethodsThis analytic cross-sectional survey used a hybrid of mixed methods stakeholder interviews coupled with prototype throw-away software development to gather data from 50 public primary health facilities and 50 private primary care centers in Abuja, Nigeria. Data gathered documents costs relevant for a reliable and sustainable mobile-supported health insurance system. Clients and health workers were interviewed using structured questionnaires on services provided and cost of those services. Trained interviewers conducted the structured interviews, and 1 client and 1 health worker were interviewed per health facility. Clinic expenditure was analyzed to include personnel, fixed equipment, medical consumables, and operation costs. Key informant interviews included a midmanagement staff of a health-management organization, an officer-level staff member of a mobile network operator, and a mobile money agent. ResultsAll the 200 respondents indicated willingness to use the proposed system. Differences in the cost of services between public and private facilities were analyzed at 95% confidence level (P

Contrast-enhanced fat-suppressed T1 weighted (T1W) two-dimensional (2D) turbo spin echo (TSE) and magnetization-prepared gradient echo (MPRAGE) sequences with water excitation are routinely obtained to evaluate orbit pathology. However, these sequences can be marred by artefacts. The radial-volume-interpolated breath-hold examination (VIBE) sequence is a motion-robust fat-suppressed T1W sequence which has demonstrated value in paediatric and body imaging. The purpose of our study was to evaluate its role in assessing the orbit and to compare it with routinely acquired sequences.A Health Insurance Portability and Accountability Act-compliant and institutional review board-approved retrospective study was performed in 46 patients (age range: 1-81 years) who underwent orbit studies on a 1.5-T MRI system using contrast-enhanced Radial-VIBE, MPRAGE and 2D TSE sequences. Two radiologists blinded to the sequence analysed evaluated multiple parameters of image quality including motion artefact, degree of fat suppression, clarity of choroidal enhancement, intraorbital vessels, extraocular muscles, optic nerves, brain parenchyma and evaluation of pathology. Each parameter was assessed on a 5-point scale, with a higher score indicating the more optimal examination. Mix model analysis of variance and interobserver variability were assessed.Radial-VIBE demonstrated superior quality (p 0.001) for all orbit parameters when compared with MPRAGE and 2D TSE. Interobserver agreement demonstrated average fair-to-good agreement for degree of motion artefact (0.745), fat suppression (0.678), clarity of choroidal enhancement (0.688), vessels (0.655), extraocular muscles (0.675), optic nerves (0.518), brain parenchyma (0.710) and evaluation of pathology (0.590).Radial-VIBE sequence demonstrates superior image quality when evaluating the orbits as compared with conventional MPRAGE and 2D TSE sequences.Radial-VIBE employs unique non-Cartesian k-space sampling in a radial or spoke-wheel fashion which provides superior image quality improving diagnostic capability in the evaluation of the orbits.

Standard crossnational measures of corruption draw on information collected through surveys. We propose a novel alternative measure based on objective data, namely, the difference between a measure of the physical quantities of public infrastructure and a measure of the value of public capital stocks. Where the difference between the value of existing infrastructure and the actual physical infrastructure is larger, more money is being siphoned off in mismanagement, fraud, bribes, kickbacks, and embezzlement; that is, corruption is greater. We create this measure for Italy's 20 regions as of the mid-1990s, controlling for possible regional differences in the costs of public construction. We analyze data over the Italian regions to demonstrate the utility of the proposed measure. The analysis shows that corruption is greater in the southern Italian regions, as would be expected. Our proposed measure exhibits a strong statistically significant relationship inverse with Putnam's measure of government performance, suggesting that as corruption increases, government performance deteriorates. Finally, we show that high-level political malfeasance measured by the number of charges of malfeasance against members of Italy's Chamber of Deputies in the period from 1992 to 1994 is highly and significantly correlated with the more general measure of corruption that we propose.

The examination of health disparities among people within Appalachian counties compared to people living in other counties is needed to find ways to strategically target improvements in community health in the United States of America (USA). Methods: A telephone survey of a random sample of adults living in households within communities of all counties of the state of Virginia (VA) in the USA was conducted. Findings: Health status was poorer among those in communities within Appalachian counties in VA and health insurance did not make a difference. Health perception was significantly worse in residents within communities in Appalachian counties compared to non-Appalachian community residents (30.5 vs. 17.4% rated their health status as poor/fair), and was worse even among those with no chronic diseases. Within communities in Appalachian counties, black residents report significantly better health perception than do white residents. Conclusion: Residents living in communities in Appalachian counties in VA are not receiving adequate health care, even among those with health insurance. More research with a larger ethnic minority sample is needed to investigate the racial/ethnic disparities in self-reported health and health care utilization within communities.

There is currently no public financial system that fully covers enteric fever suspects in China. This study aimed at documenting the level of access to definitive diagnostic procedures, especially haemoculture, for these patients and examining the effect of health insurance on access to such care. A hospital-based cross-sectional study was conducted in six counties of Yunnan province, using a structured questionnaire and data extraction from medical records. In total, 714 subjects were recruited. Chi-square test and logistic regression were employed for analysis of data. The majority of the subjects were young adults (52%) and farmers (55%) from low-income families (49%). Only 407 (57%) could afford haemoculture routinely advised by their doctors. Of these, 123 (30%) had haemoculture positive for Salmonella Typhi. After adjustment for income, not getting haemoculture was marginally associated with percentage of reimbursement from the insurance (p value for trend=0.047). Illiteracy was also an independent risk factor for this outcome. The poor coverage of haemoculture for patients suspected of having enteric fever in this endemic area was due to financial barrier. The current health-insurance system inadequately relieved the problem. Further financial reform to help patients suspected with enteric fever is required.

We estimate a Logit model for the choice determinants of the mobility in the Dutch market for health insurance in 2006. The results highlight that socio-economic, geographical, and health-related factors matter in the decision to switch health care insurer. Moreover, previous contact with the insurer and the former type of health policy are also of influence.

Background: Traditional metrics of the impact of the Affordable Care Act (ACA) and health insurance marketplaces in the United States include public opinion polls and marketplace enrollment, which are published with a lag of weeks to months. In this rapidly changing environment, a real-time barometer of public opinion with a mechanism to identify emerging issues would be valuable. Objective: We sought to evaluate Twitter’s role as a real-time barometer of public sentiment on the ACA and to determine if Twitter sentiment (the positivity or negativity of tweets) could be predictive of state-level marketplace enrollment. Methods: We retrospectively collected 977,303 ACA-related tweets in March 2014 and then tested a correlation of Twitter sentiment with marketplace enrollment by state. Results: A 0.10 increase in the sentiment score was associated with an 8.7% increase in enrollment at the state level (95% CI 1.32-16.13; P =.02), a correlation that remained significant when adjusting for state Medicaid expansion ( P =.02) or use of a state-based marketplace ( P =.03). Conclusions: This correlation indicates Twitter’s potential as a real-time monitoring strategy for future marketplace enrollment periods; marketplaces could systematically track Twitter sentiment to more rapidly identify enrollment changes and potentially emerging issues. As a repository of free and accessible consumer-generated opinions, this study reveals a novel role for Twitter in the health policy landscape. [J Med Internet Res 2015;17(2):e51]

BACKGROUND: Online cancer-related support is an under-studied resource that may serve an important function in the information seeking, care, and support of cancer patients and their families. With over 9.8 million cancer survivors (defined as anyone living with cancer) in the United States alone and the number growing worldwide, it is important to understand how they seek and use online resources to obtain the information they need, when they need it, and in a form and manner appropriate to them. These are stated cancer communication goals of the US National Cancer Institute. OBJECTIVES: Our purposes are to (1) present background information about online mailing lists and electronic support groups, (2) describe the rationale and methodology for the Health eCommunities (HeC) study, and (3) present preliminary baseline data on new subscribers to cancer-related mailing lists. In particular, we describe subscribers' use of mailing lists, their reasons for using them, and their reactions to participating shortly after joining the lists. METHODS: From April to August 2004, we invited all new subscribers to 10 Association of Cancer Online Resources mailing lists to complete Web-based surveys. We analyzed baseline data from the respondents to examine their perceptions about cancer-related mailing lists and to describe how cancer patients and survivors used these lists in the period shortly after joining them. RESULTS: Cumulative email invitations were sent to 1368 new mailing list subscribers; 293 Web surveys were completed within the allotted time frame (21.4% response rate). Most respondents were over age 50 (n = 203, 72%), white (n = 286, 98%), college graduates (n = 161, 55%), and had health insurance (n = 283, 97%). About 41% (n = 116) of new subscribers reported spending 1 to 3 hours per day reading and responding to list messages. They used the mailing lists for several reasons. Among the most frequently reported, 62% (n = 179) strongly agreed they used mailing lists to obtain information on how to deal with cancer, 42% (n = 121) strongly agreed they used mailing lists for support, and 37% (n = 109) strongly agreed that they were on the mailing lists to help others. Smaller proportions of new subscribers strongly agreed that others on the mailing lists had similar cancer experiences (n = 23, 9%), that they could relate to the experiences of others on the lists (n = 66, 27%), and that others on the list gave them good ideas about how to cope with cancer (n = 66, 27%). CONCLUSIONS: Cancer-related online mailing lists appear to be an important resource, especially for information seeking but also for support of cancer survivors. These were the primary motivators most members reported for joining mailing lists. The modest proportion of subscribers who strongly agreed that they could relate to others' cancer experiences (as well as similar responses to other process questions) is undoubtedly due at least in part to the short duration that these subscribers were involved with the mailing lists. Emerging data, including our own, suggest that mailing lists are perhaps under-used by minority patients/survivors. These preliminary data add to a growing body of research on health-related online communities, of which online mailing lists are one variant. [J Med Internet Res 2005;7(3):e32]